PALS

Initial Assessement

Airway

• Provide 100 percent inspired oxygen
• Allow the child to assume a position of comfort or manually open the airway
• Clear the airway (suction)
• Insert an airway adjunct if consciousness is impaired (eg, nasopharyngeal airway or, if gag reflex absent, oropharyngeal airway)
• If the patient is unresponsive without signs of life, begin chest compressions immediately

Breathing

• Assist ventilation manually in patients not responding to basic airway maneuvers or with inadequate or ineffective respiratory effort
• Monitor oxygenation by pulse oximetry
• Monitor ventilation by end-tidal carbon dioxide (EtCO2) if available
• Administer medications as needed (eg, Salbutamol for status asthmaticus, inhaled racemic epinephrine for croup)

Circulation

• monitor heart rate, rhythm, and establish vascular access
• Access shock

Shock

• PALS Definition of hypotension
  • Term neonates (0 to 28 days): <60 mmHg
  • Infants (1 to 12 months): <70 mmHg
  • Children (1 to 10 years): <70 mmHg + (child's age in years x 2)
  • Children >10 years: <90 mmHg

Types of shock

• Hypovolemic
• Distributive
• Cardiogenic
• Obstructive

Disability

• AVPU pediatric response scale: Alert, Voice, Pain, Unresponsive
• Pupillary response to light
• Presence of hypoglycemia (rapid bedside glucose or response to empiric administration of dextrose)
• Glasgow Coma Scale: Eye Opening, Verbal Response, Motor Response (for trauma patients)

Second Assessment

This portion of the evaluation includes a thorough head to toe physical examination, as well as a focused medical history that consists of the "SAMPLE" history:

• S: Signs and symptoms
• A: Allergies
• M: Medications
• P: Past medical history
• L: Last meal
• E: Events leading to current illness

Cardiopulmonary failure

• Respiratory failure and hypotensive shock are the most common conditions preceding cardiac arrest.

Causes of respiratory failure include:

• Upper airway obstruction (choking, infection)
• Lower airway obstruction (asthma, foreign body aspiration)
• Parenchymal disease (pneumonia, acute pulmonary edema)
• Disordered control of breathing (coma, toxic ingestion, status epilepticus)

Causes of hypotensive shock include:

• Hypovolemia (dehydration, hemorrhage)
• Cardiac failure (eg, due to myocarditis or valvular disease)
• Distributive shock (septic, neurogenic)
• Metabolic/electrolyte disturbances
• Acute myocardial infarction/ischemia
• Toxicologic ingestions
• Pulmonary embolism

Bradycardia

Signs of sinus bradycardia

• slowing of heart rate relative to normal values
• PR interval normal
• in healthy children

Signs of pathogenic bradycardia

• Slow heart rate relative to normal rates
• P waves that may or may not be visible
• QRS complex that is narrow (electrical conduction arising from the atrium or high nodal area) or wide (electrical conduction from low nodal or ventricular region)
• P wave and QRS complex may be unrelated (ie, atrioventricular dissociation) or have an abnormally long period between them (atrioventricular block)

Tachycardia

Signs of sinus Tachycardia

• Heart rate is usually <220/min in infants, <180/min in children, and exhibits beat to beat variability in rate.
• P waves are present with normal appearance.
• PR interval is constant and exhibits a normal duration for age.
• R-R interval is variable.
• QRS complex is narrow.

Pathogenic tachycardia

SVT

• Heart rate that is usually >220/min in infants, >180/min in children, and has no or minimal beat to beat variability.
• P waves are absent or abnormal.
• PR interval may not be present or short PR interval with ectopic atrial tachycardia.
• R-R interval is usually constant.
• QRS is usually narrow. Conduction delay along the ventricular system may lead to an appearance of wide complex tachycardia, known as SVT with aberrant conduction.

VT

• Ventricular rate is >120 beats per minute and regular.
• P waves are often not identifiable, may have AV dissociation, or may have retrograde depolarization.
• QRS is typically wide (>0.09 seconds).
• T waves are often opposite in polarity from the QRS complex.